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The role of the pelvic floor in IC/BPS

The term “pelvic floor” isn’t just a clever name – these muscles literally comprise the floor of your pelvis. In a previous post I described the anatomy and physiology of this underappreciated muscle group. IC/BPS is intricately linked to the pelvic floor muscles and all of the fascia and nerves that reside in this region. These muscles are often tight and develop trigger points (painful “knots” that are exquisitely tender and can refer pain elsewhere) in individuals with IC/BPS. This chronic tension irritates nerves in this region which run through the pelvis, causing pain in the pelvis, groin, abdomen, buttocks, and back. The brain can also interpret this signal as an urgent need to urinate, even if you went 5 minutes ago.

Pelvic floor physical therapy is the ONLY treatment given an evidence grade of “A” by the American Urologic Association and is the recommended first line of treatment for IC. The goal of PT is to reduce tightness and tension in the muscles of the pelvic floor, which decreases pain and allows them to function normally. Pelvic floor PTs are also trained to release restrictions in pelvic fascia, a thin connective tissue that surrounds all of our organs, nerves, bones, and muscles. This reduces inflammation and pain and increases blood flow to the region. Your PT should teach you ways to manage this tension on your own, too. Foam rolling, therawands, yoga poses and stretches for relaxing affected muscles, and diaphragmatic breathing are all helpful tools patients can use regularly to maintain gains achieved in PT and further their progress. Additionally, pelvic floor PTs are adept at teaching patients ways to downregulate their nervous system, a topic of an upcoming post, and helping patients navigate dietary triggers and ways to manage stress. In short, an experienced pelvic floor PT is an integral component to addressing the symptoms of IC/BPS.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872169/

https://pubmed.ncbi.nlm.nih.gov/23234638/

http://www.auanet.org/guidelines/interstitial-cystitis-(ic/bps)-guideline

Nervous System Upregulation

The brain and spinal cord constantly send and receive signals to and from your muscles and organs to regulate function and to maintain homeostasis. When someone has been in pain for more than 3 months researchers believe these signals become amplified. Signals coming from muscles and/or visceral structures may short circuit and the spinal cord amplifies a normally harmless pain signal, causing it to be interpreted as excruciating. Harmless stimuli may be experienced as dangerous and intensely painful, and the threshold for pain is decreased. Additionally, the brain begins paying much closer attention to the affected regions of the body and is on high alert constantly. The nerves get used to firing more frequently and the brain becomes accustomed to receiving these pain signals, so the threshold for pain is lowered. This is upregulation of the nervous system.

This upregulation has several consequences. In the case of pelvic floor dysfunction the pelvic nerves become overstimulated, referring pain throughout the pelvis and causing pelvic floor pain, coccyx pain, lower back pain, urinary symptoms, and pain during sex. If the bladder is one of the affected structures, as in IC/BPS, the nerves report the bladder is already full despite the fact it was emptied 5 minutes prior. The referring nerves connecting the bladder to the pelvic region can also become hypersensitized, causing suprapubic tenderness. Incidentally, the bladder has the highest nerve density of any organ, so this is a super important concept for anyone with bladder and pelvic floor issues to understand.

Addressing this upregulation of the nervous system is an integral component of treatment for anyone with bladder, pelvic floor, and abdominal wall pain (Actually, it should be part of a comprehensive treatment plan for ANYONE with ANY kind of pain!). Reducing this hypersensitivity can greatly reduce one’s symptoms and keep them at bay. These nerves have likely been overstimulated for a long time, so downregulating them may take some time and practice. Pelvic floor physical therapists use many techniques including myofascial release, soft tissue techniques, diaphragmatic breathing, exercise, mindfulness, meditation, and, most importantly, education to help patients reclaim function and quality of life.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5498792/

Physical activity has been shown to decrease the risk of breast cancer. An expert panel of the International Agency for Research on Cancer of the World Health Organization estimated a 20%-40% decrease in the risk of developing breast cancer among the most physically active women, regardless of menopausal status, type, or intensity of activity. Interestingly, a study published in the Journal of the American Medical Association found that physical activity improved survival rates in women after a breast cancer diagnosis, particularly among women with hormone-responsive tumors. Physical therapists are uniquely suited to work with patients during and after treatment for cancer and can modify and tailor individual exercise programs based on one’s impairments, goals, and any side effects from treatment, such as fatigue or nausea.

https://jamanetwork.com/journals/jama/article-abstract/200955

Up to 50% of individuals undergoing treatment for breast cancer experience shoulder dysfunction and pain. All too often, however, most of these patients are not referred to PT. This systematic review promotes physical therapy as an evidence-based treatment for this population to treat and prevent shoulder problems through tailored exercise prescription, hands-on techniques, pain science education.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970094/

When one is undergoing treatment for breast cancer the focus is on the breast and lymphatic system, naturally. Scar management, lymphatic dysfunction, reconstructive procedures, upper extremity function are all obvious rehabilitation concerns during and post-breast cancer treatment. Women are living longer after breast cancer treatment ends, though, and we need to consider the long-term effects of having breast cancer and the interventions used to treat it on the pelvic floor and genitourinary system.

Pelvic floor issues can be a barrier to exercise, which impacts one’s ability to manage stress, improve bone density, manage one’s weight, decrease risk of cancer recurrence, and improve cardiovascular function. In fact, 20% of women who die after being diagnosed with breast cancer die from a heart attack due to the cardiotoxic effects of some chemotherapy drugs, effects of radiation therapy, and/or the decreased amount of circulating estrogen in the body. Exercise and stress management are vital for cardiovascular health, and pelvic floor physical therapists can not only help breast cancer survivors learn strategies to exercise safely without causing or increasing pelvic floor issues, but can also create bespoke exercise programs tailored to each patient’s needs and goals.

Many of the treatment options for breast cancer have side effects of ovarian suppression/removal, which is important in hormonally-driven cancers. Unfortunately, this decrease in bioavailable estrogen negatively impacts the tissues of the pelvic floor. The tissues in the perineum contain an abundance of estrogen receptors. As estrogen levels plummet, these tissues become more fragile and less elastic. This can lead to pain during intercourse, which can further affect one’s already fragile self-esteem and body image. Pelvic floor PTs are adept at addressing pelvic pain and sharing strategies with patients to decrease pain during sex, such as manual therapy techniques, positioning, lubricants, and dilators.

Estrogen suppression can also contribute to constipation, stressing the lymphatic system (which may be compromised by surgery and/or radiation). Constipation also increases the risk of urinary incontinence, is correlated with urinary frequency and urgency, and increases risk of anal incontinence. Toileting strategies, addressing pelvic floor coordination, movement strategies, dietary considerations are interventions pelvic floor therapists use regularly to address constipation. It should also be noted that tamoxifen has been shown to be positively correlated with urinary incontinence, a fact many patients are unaware of.

Pelvic organ prolapse is another common diagnosis after undergoing treatment for breast cancer due to declining estrogen levels and constipation. Additionally, chemotherapy can cause decreased muscle mass. If the muscles of the arms and legs are weaker, one may strain during exertion or when lifting or going from sitting to standing. This increase in intraabdominal pressure may overload the muscles and supporting connective tissue of the pelvic floor over time, contributing to symptoms of prolapse. Learning strategies to manage intraabdominal pressure, understanding how to correctly coordinate the pelvic floor muscles, and managing constipation are key in avoiding/decreasing pelvic organ prolapse, and a pelvic floor PT can assist with all of this.

Lastly, reconstructive procedures using abdominal tissues and resultant scarring also significantly impact the function of the pelvic floor and impact bowel and bladder health. Patients who undergo these interventions would greatly benefit from seeing a pelvic health PT to address the myofascial and visceral effects of these procedures.

I realize these issues may not be at the forefront of one’s mind while going through breast cancer treatment, but they significantly impact one’s quality of life. Thank goodness women are living longer after being diagnosed with breast cancer. These women deserve to live without pain, incontinence, body image issues, or limitations, and pelvic health physical therapists are uniquely suited to help them achieve that goal.

November is National Bladder Awareness month! Let’s kick it off with some information about urinary urgency and frequency!

Frequent urination describes the need to urinate more often than usual. A “normal” voiding interval is 2-4 hours. I see patients who are urinating as often as every 20 minutes. Obviously, this can be incredibly frustrating and can take a significant toll on one’s quality of life. I’m frequently told by patients, “I know where every bathroom is in Bloomingdale’s,” or, “When I run errands I plan my day around where I know restrooms are.” Urinary urgency is an overwhelming need to get to a restroom immediately. It may be accompanied by bladder pain, and individuals experiencing this may not be able to make it to the toilet in time.

Urinary urgency and frequency often occur together. Common causes of urgency and frequency include (but are not limited to): increased consumption of water, diuretics, third trimester of pregnancy, prostate enlargement, anxiety, diabetes, Interstitial Cystitis/Painful Bladder Syndrome, urinary tract infection, constipation, and overactive pelvic floor muscles. Another contributor can be foods or beverages that are bladder irritants. These may include coffee, tea, carbonated beverages, acidic foods/juices, vinegars, chocolate, tomatoes, sugar, artificial sweeteners, and alcohol. These items contain substances that may irritate the lining of the bladder, causing increased urge to urinate. Everyone reacts to these substances differently, so what aggravates one person’s symptoms may be very well tolerated by someone else.

Up next: how pelvic floor physical therapy can help!

How can pelvic floor PT help with urinary urgency and frequency?

A bladder diary can be helpful to recognize patterns and triggers. It essentially involves documenting every time you urinate and how much you voided, what you ate, what you drank and the volume of what you drank, and if you experienced incontinence (loss of urine).

A helpful technique pelvic floor PTs use is bladder retraining. I gave a basic description of the anatomy of the urinary system in my post about stress incontinence. The bladder is a sac made of smooth muscle and it slowly stretches and expands outwards and upwards as it gradually fills with urine. The bladder holds approximately 2 cups of urine. As the bladder fills, stretch receptors in the bladder walls are activated, and once the bladder fills to a certain capacity these receptors notify the brain that the bladder needs to be emptied. We can usually defer urination if we aren’t near a restroom or if it’s inconvenient to go at the moment, but eventually this urge will become more intense and we’ll have to find a toilet. Once we’re on the toilet the bladder contracts and the spincters around the urethra (the tube that runs from the bladder through which urine exits) relax, and we urinate.

If a patient’s voiding interval (time between peeing) is 30 minutes and our goal is to increase that interval to 2 hours, we’ll try bladder retraining. We may start by increasing her voiding interval to 45 minutes. If she experiences urgency prior to the voiding interval goal she can use techniques I will have taught her to quiet the urge to urinate until it’s been 45 minutes. Once she can make it to 45 minutes we’ll increase the interval a little more, and so on.

Two important notes on urgency/frequency. Patients with these symptoms (and patients who experience incontinence) often limit the amount of fluid they drink. If you drink less, you’ll pee less, right? Wrong. If you don’t drink enough water not only will you be dehydrated, but your urine will also become concentrated. This concentrated urine is a bladder irritant and will increase your urge to go. So please drink your water! Another common activity I hear about in this population is what I call JIC’ing. They pee “just in case” constantly. They may not need to urinate at that moment, but they’re walking by a restroom or about to leave the house so they go “just in case.” If you habitually urinate when you don’t have to actually trains your bladder to tell you it needs to be emptied when it’s partially full rather than mostly full. So, NO jic’ing!

Pelvic floor physical therapists can also help with the symptoms of urinary urgency and frequency through a variety of techniques. A good pelvic floor PT will always assess a patient’s breathing mechanics, spinal mobility, alignment/posture, visceral and soft tissue mobility, pelvic floor muscle strength and tone as impairments in any of these can contribute to urgency and frequency. We’ll also discuss fluid intake, diet, activity levels, and a patient’s stress levels. Every treatment program should be unique to the particular patient and take his/her goals into account.

If you’re experiencing the urge to urinate often and/or intensely, you may want to consider consulting a physical therapist who specializes in treating individuals with pelvic floor dysfunction. We can help restore your quality of life so you aren’t constantly worrying about where the bathroom is!

An Important Caveat to Pelvic Floor Strengthening…

When most people hear “pelvic floor therapy” they assume kegels, or pelvic floor muscle strengthening exercises, will be in the plan. Pelvic floor strengthening is vital for some patients and can play a major role in decreasing symptoms in individuals dealing with incontinence or pelvic organ prolapse. The majority of the patients I treat, however, do not need to do exercises to strengthen their pelvic floor musculature. In fact, this kind of exercise will most likely make their symptoms worse.

Many women and men have hyperfacilitated, shortened, overactive pelvic floor muscles. This could be due to an injury, surgery, trauma, chronic pain, incoordination, and/or abuse. Let’s use your bicep (the muscle in front of your upper arm that runs from the shoulder to the elbow) as an example. If your bicep was shortened you wouldn’t be able to fully straighten your elbow. You may only be able to move halfway through your normal range of motion. After a while this muscle would start to ache and feel uncomfortable. Other muscles in the area that would start to compensate for the lack of mobility in your elbow, and they would also start to feel tight and painful. You wouldn’t have as much strength as you usually do since your bicep couldn’t move through its full excursion. This can happen to the muscles in the pelvic floor as well, resulting in chronic pain and impaired function. It can also cause incontinence. Shortened pelvic floor muscles have significantly less range of motion to shorten and lengthen as they usually do. Without this ability to fully contract and relax their ability to do their jobs – provide stability to the pelvis and spine, contract during orgasm, keep us from leaking urine and feces, allow us to completely evacuate our bladder and bowel, support the organs in our abdominopelvic cavity – is significantly impaired.

If you are experiencing pelvic pain and/or suspect your pelvic floor muscles are overactive, please DON’T do kegels. Consider consulting a provider specializing in rehabilitation of the pelvis and abdomen. We are trained in various techniques to quiet and soften these muscles, such as myofascial release, mobilization of viscera, joint mobilizations, diaphragmatic breathing, stretches, and EMG, to name a few. We can teach you how to work on problem areas yourself. We’ll help determine what’s driving the pain and chronic muscle tension and how to best address it.

DIASTASIS RECTUS ABDOMINIS

Women frequently come see me postpartum for treatment of diastasis rectus abdominis (DRA). There’s a great deal of misinformation out there about what DRA is and how it’s treated, so let’s start tackling some of this misunderstanding!

We’ll begin with a little anatomy lesson. We have 4 layers of abdominal musculature. From superficial to deep they are the rectus abdominis, external oblique, internal oblique, and transverse abdominus. Each muscle has its own “job” but they all work together to stabilize the torso and pelvis and to manage intraabdominal pressure. They also impact how we breathe. We have a left and a right and the two sides meet in the midline of the abdomen and attach to fascia called the linea alba. The linea alba runs from the bottom of the ribcage and xiphoid process down to the top of the pelvis, or pubis. The left and right sides of the abdominal wall transmit force through the linea alba.

During pregnancy the linea alba thins and the rectus abdominis muscle bellies migrate laterally on the abdomen to make room for the growing baby. The linea alba does not split or tear, which is a common misconception. This is a DRA, and some studies estimate that 100% of women by 35 weeks gestation have a DRA. This is normal and needs to happen.

Typically the abdominal wall regains the ability to function and generate tension across the linea alba postpartum. Relaxin will continue to be produced if a woman is breast feeding. This can impact the stability of joints, ligaments, and the fascial system, and may contribute to a longer recovery period. One third of postpartum women, however, do not regain previous function of the abdominal wall and their DRA remains after giving birth. This impaired ability of the abdominal wall to effectively stabilize and manage pressure may lead to a host of issues and can significantly impact a woman’s self-esteem.

Up next: signs and symptoms of a DRA and how to assess it!

Diastasis Rectus Abdominis Part II

The most frequent complaint I hear from women with a DRA is that they’re unhappy with how their tummy looks. They often say they feel like they still look pregnant or that they have a “pooch.” Some will note the midline of their abdomen is saggy. Many report that their abdominal wall domes or tents when they sit up from bed, lift their head from lying down, or lift their children. This is all due to the abdominal muscles’ impaired ability to work as a team to stabilize the trunk and appropriately manage increases in pressure in the abdomen.

Some women with DRA also experience pelvic organ prolapse (POP), urinary and/or fecal incontinence, lower back pain, pelvic girdle pain. Developing any of these conditions is not a definite consequence of having a DRA, but it does make sense that these issues could arise. If a woman is unable to use her abdominal wall to help provide stability other muscles will try to compensate. Frequently the pelvic floor muscles will become overactive (which could lead to pelvic pain, painful sex, incontinence, POP) in an attempt to pick up the slack for an inefficient abdominal wall. Muscles in the lower and midback may also get overrecruited and become tight and sore. Women with DRA will often use their diaphragm to stabilize their torso and breath hold when lifting, carrying, etc. This strategy could also possibly contribute to the development of POP, incontinence, breathing difficulties, and pelvic or back pain.

Kai Bo et al published a study in 2017 that looked at 300 women who were pregnant for the first time at gestational week 21 and then 6 weeks, 6 months, and 12 months postpartum. The participants were assessed for a DRA at each visit as well as for POP and urinary incontinence. Participants with DRA were not more likely to have POP or incontinence. Interestingly, a study by Spitznagle et al looked for a correlation between DRA and pelvic floor dysfunction in an older patient population (514 subjects, mean age = 52.45). They found a statistically significant correlation between a diagnosed DRA and pelvic organ prolapse, fecal incontinence, and urinary incontinence. More research certainly needs to be done to determine the potential long-term sequelae of an untreated DRA, but it makes sense that if compensatory patterns are adopted due to an inefficient abdominal wall, things could eventually break down and other issues may arise. If this doesn’t make sense it may help to review a previous post that describes the pistoning relationship between the pelvic floor, diaphragm, and abdominal wall.

https://pubmed.ncbi.nlm.nih.gov/27037746/

https://journals.lww.com/jwhpt/Citation/2007/31010/The_Relationship_Between_Diastasis_Recti_Abdominis.20.aspx

Assessing DRA

I assess the abdominal wall of any patient who comes to see me postpartum and with any pelvic floor, pelvic girdle, or lower back issues. If someone has been assessed for a DRA by their medical provider or a trainer they’ve usually had someone palpate their abdomen at the level of their belly button to determine how many fingers will fit between the recti muscles at rest and when they lift their head and shoulder blades. This assessment is often also done above and below the belly button. This is how many PTs, fitness professionals, and medical providers have been taught to assess DRA. It’s also important, however, to assess resting tension of the linea alba, the tension in the linea alba during a head lift, and how easily the recti can be pulled apart. In fact, I might argue this information is more important. You see, for years DRA has been regarded as a gap that had to be closed. Patients and their providers would obsess about the size of the gap between the rectus abdominis muscle bellies. Women have been instructed to wear girdles or have had their tummies taped to help “close” this gap. Women were given exercises during which they’d have a towel or sheet wrapped around their abdomens to approximate the separated recti in hopes this would encourage the muscles to approximate. These treatments have proven ineffective.

Research done by Diane Lee et al (https://pubmed.ncbi.nlm.nih.gov/27363572/) has shown that, in fact, when the abdominal wall works as a cohesive unit and transverse abdominis (the deepest layer of abdominal musculature) turns on before someone lifts her head the recti muscle bellies actually separate, or move laterally, BUT more tension is produced in the linea alba. This means the linea alba is efficiently transferring force, allowing the abdominal muscles to effectively “talk” and work as a cohesive unit. This coordination and motor sequencing should happen automatically and needs to be retrained in someone with a DRA. This has been corroborated by other researchers but there’s still a lack of robust research on this topic.

I realize this may be WAY more information anyone ever wanted to know about the neuromotor control of the abdominal wall, but I think it’s extremely important for both providers and the patients they treat to understand the biomechanics of the abdominal wall in order to effectively restore function. It isn’t about the gap, it’s about the tension someone generates in that linea alba. Here’s a quick YouTube clip of Diane Lee demonstrating how she evaluates DRA:

https://www.youtube.com/watch?v=06o8Z54l-40

So….How Do We Fix a DRA?

Hopefully you now have a clearer understanding of what a DRA is and how retraining the coordination of the abdominal wall is imperative when addressing a DRA. I wish I could tell everyone, “just do these 3 exercises and you’ll be cured,” but it’s simply not that easy. Everyone is different and adopts various strategies and compensatory movement/recruitment patterns. There is no one blanket exercise program that is effective for every individual with DRA. I’m wary of exercise programs I see advertised online about DRA. I feel many prey on women’s self-esteem issues and make false claims. I also don’t believe blanket recommendations many providers put out there, such as “People with DRA should NEVER plank,” or “Crunches will make DRA worse!” Some people with a DRA can hold a plank and generate beautiful tension in the linea alba, some cannot. It all depends on the individual, how she recruits her abdominal wall muscles, her breathing strategy, if she has any twists in her thorax or pelvis, if she has soft tissue restrictions in any muscles in her thorax or abdomen, is she has pain….there are multiple variables and it’s imperative for each person to be assessed by a trained, skilled provider who has experience working with DRA and will create a bespoke, unique treatment program for the woman in front of her.

Usually addressing the impairments listed above and working diligently with a proficient provider will help restore the function and appearance of the abdominal wall. Sometimes, however, conservative intervention may not be enough and surgery may be recommended. I haven’t heard of any insurance companies covering this procedure yet, sadly, as they regard DRA repair as cosmetic and elective. Hopefully more robust research will be published in the near future to prove those who do not respond to PT need and deserve to have this issue attended to in order to prevent secondary issues in the future.

Along those lines, we still don’t have a clear understanding of why some people develop DRA. Certainly those with connective tissue disorders may be more at risk, but studies have shown that exercise during pregnancy (or lack thereof) does not correlate with DRA. Again, this condition needs to be researched more extensively so we can have a better understanding of how it develops and how to most effectively address it.

It’s also worth mentioning that men can develop DRA. Excess abdominal fat and overtraining the abdominal muscles are linked to DRA in men. Infants are born with DRA and this may persist into childhood, which may contribute to trunk weakness, back pain, GI disorders. Both men and kids can also benefit from the treatments described above.

If you have been diagnosed with DRA or think you may have one, find an experienced, trained provider. Do your research. Ask questions. Keep searching until you find someone you trust and feel comfortable working with. Pelvic floor PTs are a great place to start, but there are some personal trainers who have undergone special training to work with this population.

I love this study and think it should make PTs and rehab professionals reconsider how they train postmenopausal women. In the LIFTMOR trial 101 postmenopausal women who had been diagnosed with osteoporosis were randomized into two groups. One participated in a fitness training regimen consisting of high intensity interval training (HIIT) and heavy resistance training twice a week for 30 minutes under the supervision of a trained professional. These activities have traditionally been avoided when working with this population due to increased fracture risk. The other performed a home-based low-intensity exercise program. The group participating in high intensity activities demonstrated superior outcomes in bone mass and physical function, as well as increased height (!). No fractures or major adverse events occurred in either group. Exercise is a well documented modality for decreasing fall risk and increasing bone mineral density, and is highly recommended for individuals with decreased bone mineral density. These exercises should be programmed by a trained professional and rest days should be programmed in.

https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbmr.3284

Did you know the speculum OB/GYNs use during vaginal exams dates back to ancient Rome? Physicians in Pompeii were the first to manufacture and use this tool. During the Middle Ages after the fall of the Roman Empire examination of a woman’s body was considered taboo and sinful. This belief persisted into the 19th century, when only men could become physicians and men were not allowed to examine a naked woman’s body for fear she would become a sexual fiend if touched by a man (!). In 1825 a French midwife, Marie Anne Boivin, invented a vaginal speculum that could dilate the vagina and screwed into place for close examination of the cervix. Her invention evolved into the modern speculum. She is also credited with uncovering the causes of various disease of the uterus and miscarriages. There are many models of speculums OB/GYNs use now, and these exams should not be painful. If they are, speak up and let your provider know. He/She could use a different size or type of speculum. Also, if internal exams are painful you may benefit from pelvic floor PT!

I came across a study recently and found it interesting and worth sharing. As a PT I frequently assess patients’ flexibility and range of motion. Could this be a window into patients’ cardiovascular health? A study published by Yamaoto et al in the American Journal of Physiology-Heart and Circulatory Physiology in October of 2009 demonstrated a relationship between decreased trunk flexibility and arteriosclerosis in subjects older than 40. The American Heart Association recommends at least 150 minutes per week of moderate to intense aerobic activity or 75 min/week of vigorous aerobic activity (or a combination of both) spread out during the week. Should those recommendations include flexibility training in the form of stretching, yoga, or Pilates to prevent arterial stiffening? This topic certainly needs to be researched more extensively, but I think it’s food for thought for PTs, fitness professionals, and anyone 40 or older.

As a PT, I frequently hear, “Oh, my posture is terrible!” Throughout my years in practice I’ve evolved from thinking of posture in the black and white terms of good or bad. All postures are ok IF they aren’t your only posture or sustained for prolonged periods. We need a rich variety of postures and positions in our movement repertoire. You should be able to assume lots of different postures without pain or negative repercussions. It’s ok to slouch, as long as you aren’t slouching all day long (an instructor of a continuing education course once said, “slouching is the new chocolate” ). The other integral piece here is movement. We weren’t designed to sit on our backsides at a desk all day, staring at a computer screen. The tissues of our body respond to movement, and, if possible, we should be getting up from our desks at least every hour and moving around, stretching, etc.

Prolonged postures contribute to fatigue. When you’re in an inefficient position for a long period, your muscles have to work harder to hold you there. Constipation and pelvic floor hypervigilance are also consequences of maintaining slouched postures for prolonged periods. Slumping scrunches up the organs in your abdomen and pelvis, impeding effective digestion and elimination. Repeatedly sitting in a slouched posture on your tailbone puts undue strain on your coccyx and the muscles that attach to it. When you’re slouched your diaphragm cannot move through its full excursion, impairing your ability to breathe deeply which, in turn, impacts your stress response and energy levels. Aches and pains throughout the body are another common consequence of static postures.

Maintaining inefficient alignment for prolonged periods has also been shown to impact mood, self-esteem, and stress response. A study in the Journal of Health Psychology showed that participants who slouched during a stressful event were more fearful, had lower self-esteem, and were more likely to experience negative emotions than their counterparts who sat more erect. Other studies have demonstrated that participants who sat up “straight” had more self-confidence and faith in themselves.

If you don’t sit up tall in a perfectly erect posture 100% of the time, don’t beat yourself up – but don’t hunch over constantly, either. Our nervous systems love variability, so strive to keep moving as best you can throughout the day to keep your body (and mind!) supple, joyful, and healthy!

https://pubmed.ncbi.nlm.nih.gov/25222091/

https://www.sciencedaily.com/rel.../2009/10/091005111627.htm

https://psycnet.apa.org/record/2009-17720-013

I recently came across this study and think the findings are fascinating and should change the post-operative instructions patients are given after abdominal surgery. After abdominal surgery patients are typically advised not to lift more than 20lbs. Frequently performed daily activities such as going from sitting to standing or coughing, however, actually cause a greater increase in intra-abdominal pressure. Perhaps these patients would benefit from instruction on how to manage intra-abdominal pressure during activities of daily living prior to surgery from a trained health care professional such as a pelvic floor PT to better protect not only the surgical sites but also potentially vulnerable pelvic floor musculature, connective tissue, and abdominopelvic organs.

https://www.ncbi.nlm.nih.gov/pubmed/2509803

Did you know that breathing, bladder control, and bowel function are more connected to lower back pain than BMI or activity level? Many providers emphasize weight loss and physical activity modification when dealing with patients with lower back pain. While these are important pieces of the puzzle, most physicians and orthopedic PTs don’t screen patients for bowel or bladder issues, nor do they assess respiratory mechanics. Including assessment of these underrecognized influences on central stability could be game-changing when working with individuals with any kind of pain.

https://www.ncbi.nlm.nih.gov/pubmed/16515418

More proof all physical therapists should consider the pelvic floor when treating women with lower back pain: in this 2018 study out of Canada 95.3% of women with lower back pain had some form of pelvic floor dysfunction (pelvic floor muscle tenderness, pelvic organ prolapse, and/or pelvic floor weakness). Moreover, those with both lower back and pelvic girdle pain presented with higher levels of disability. If you are a PT working in orthopedics, ALL of your patients have a pelvis – check it out or ask a colleague with experience treating pelvic floor conditions to co-treat. If you are undergoing treatment for lower back pain and experience pelvic floor pain, heaviness, or incontinence please consider mentioning it to your provider so they may provide the most effective care or refer you to someone who can better help you.

https://www.sciencedirect.com/.../abs/pii/S24687812173018

More proof all physical therapists should consider the pelvic floor when treating women with lower back pain: in this 2018 study out of Canada 95.3% of women with lower back pain had some form of pelvic floor dysfunction (pelvic floor muscle tenderness, pelvic organ prolapse, and/or pelvic floor weakness). Moreover, those with both lower back and pelvic girdle pain presented with higher levels of disability. If you are a PT working in orthopedics, ALL of your patients have a pelvis – check it out or ask a colleague with experience treating pelvic floor conditions to co-treat. If you are undergoing treatment for lower back pain and experience pelvic floor pain, heaviness, or incontinence please consider mentioning it to your provider so they may provide the most effective care or refer you to someone who can better help you.

https://www.sciencedirect.com/.../abs/pii/S24687812173018

I frequently ask my patients about their stress levels, regardless of why I’m treating them, as stress often manifests physically. Over the past year I’ve witnessed more and more of my patients suffer the toxic physical and emotional effects of stress. This is an incredibly stressful time given the current pandemic and the political climate in the US, and I thought it might be helpful to explain stress and the impact it can have on our bodies and well-being.

Stress is the body’s response to physical, mental, and/or emotional pressure. It causes chemical changes in the body that can result in physical responses, such as increased heart rate, and it may also lead to feelings of frustration, anger, depression, or anxiety. This reaction is driven by the autonomic nervous system (ANS). The ANS is part of the nervous system that supplies the internal organs, including blood vessels, stomach, intestine, kidneys, liver, bladder, genitals, lungs, pupils, heart, and sweat, salivary, and digestive glands. It impacts many bodily functions including digestion, sexual response, defecation, urination, metabolism, breathing and heart rate, and blood pressure.

Many people are familiar with two divisions of the ANS, the sympathetic and parasympathetic nervous systems. The sympathetic nervous system prepares us for emergency, high-stress situations. It increases heart rate, dilates airways and blood vessels, and increases energy to skeletal muscles to we can flee a predator. It slows bodily processes that are less important in emergencies such as urination and digestion. The sympathetic nervous system is often referred to as our “fight or flight” response. Our cavewoman ancestors experienced a sympathetically mediated surge of adrenaline and cortisol when they were being chased by a lion.

The parasympathetic nervous system, in contrast, is our “rest and digest” response. When this division of the nervous system is functioning, energy is used to restore and build tissues. Heart and respiratory rates slow. The digestive tract processes food and eliminates waste. This is accomplished via the vagus nerve. The parasympathetic nervous system brought our aforementioned ancestor’s heart rate and blood pressure back to resting levels after she escaped the lion and was back in the cave with her family.

So what happens when the symbiotic relationship between these two divisions of the ANS go awry? Stay tuned!

We need both of these divisions of the autonomic nervous system to be in good working order to function safely and optimally in the world. Stress isn’t necessarily a bad thing – without it, we wouldn’t be able to quickly fight an attacker or escape a dangerous situation. The problem is when we react to traffic jams, family issues, and/or pressure at work with the same response would if a lion was chasing us, and this response never fully finishes. This chronic, constant heightened sympathetic response has been shown to contribute to obesity and high blood pressure, promote the formation of artery-clogging deposits, and cause changes in the brain which contribute to anxiety, depression, and addiction.

This prolonged, exaggerated response to stress can also play a role in the consolidation of fear-based memories. Several studies have documented the link between musculoskeletal pain and pain-related psychosocial stress. It makes sense that if something has caused pain in the past, your brain will remember that and try to avoid similar situations, right? This becomes problematic when stimuli which is usually nonthreatening is perceived as painful. For example, a large portion of my caseload is women suffering with pelvic pain. For many of these women, a light touch on the abdomen or inner thigh is terrifying and anxiety-provoking. They are unable to wear jeans or tight pants, ride a bike, sit in a car. Urination and defecation are often difficult and increase their symptoms, and forget about having sex or using a tampon. Their brains are on high alert constantly to avoid any stimuli that may provoke pain. Often, muscles around the abdomen, pelvis, buttocks, and lower back are unconsciously clenched. This muscle guarding is a protective response but it can perpetuate and increase pain.

Clearly, this heightened, protracted response to stress isn’t great for our emotional, mental, or physical well-being. Up next: what can we do about it?

OK, so I think we can all agree that chronic stress isn’t doing us any favors. How can we combat this? One evidenced-based strategy to activate the parasympathetic nervous system is to simply breathe, especially if emphasis is on exhalation.

Here is a video of the brilliant Jill Miller demonstrating a few breath techniques in various positions which promote relaxation by facilitating the parasympathetic nervous system via the vagus nerve. Hopefully it helps you enjoy a relaxing Sunday! 😊

https://www.youtube.com/watch?v=dkJDrfL90rU

More ways to manage stress!

There are hundreds of studies demonstrating the link between mindfulness and meditation and an improved stress response. These strategies can be helpful during a stressful time, but it may take a little practice. You wouldn’t run a marathon without training, and meditation also takes practice. There are lots of awesome apps for meditation. A lot of people like Headspace and Calm, and I personally use Ten Percent and Insight Timer. You can choose a meditation specific for your mood or an issue you’re dealing with, like having less patience with your kids, insomnia, or fear about COVID-19. There are meditations that last 1 minute, and others that are up to an hour.

Another great strategy for combating stress is physical exercise. This deepens breathing, alleviates muscle tension, and is a fantastic positive outlet. During moderate to high intensity exercise endorphins are released. Endorphins are “feel good” hormones that bond to opiate receptors in the brain and have been shown to boost mood, reduce anxiety, and improve sleep. Restorative practices like yoga, tai chi, and Pilates have also been shown to dampen the sympathetic response.

Social support has been demonstrated to increase longevity and help us ride out stressful situations. Research has documented the many physiological and mental health benefits of social support including improved immune, cardiovascular, and neuroendocrine function; decreased depression and anxiety; enhanced self-esteem; and improved ability to buffer against negative effects of stress. Talking to a trusted friend or loved one can be incredibly therapeutic, and even small talk with neighbors, acquaintances, and coworkers can help us feel more connected and less anxious. Affection is a powerful way to discharge stress, as is having a good cry. Laughing has been shown to increase relationship satisfaction, promote muscle relaxation, increase oxygen intake, reduce stress, and may even increase immunity.

Many people are more isolated than they’d like to be, especially during the current COVID-19 pandemic. The loneliness and isolation many are experiencing now are taking a serious toll. We’re all learning new ways to connect during this period of social distancing, and apps like Zoom, Duo, and FaceTime have been invaluable. If you are feeling especially vulnerable it may be wise to seek the help of a mental health provider.

February is National Heart Month and Go Red for Women initiative, so I'll be posting a lot about women and heart health over the coming weeks. Cardiovascular disease is the #1 killer of women, causing 1 in 3 deaths annually in the US. That's 1 about woman every minute! Since 1984 more women than men have died from heart disease, the gap between survival of women and men continues to widen. Let's learn more about this to help our sisters, mothers, friends, kids, and ourselves!

Heart disease can take many forms. The most well known is atherosclerosis, often called "hardening of the arteries." This condition develops when plaque builds up in the walls of arteries, narrowing the vessels and thereby restricting blood flow. Arrhythmias (altered heart rhythm), heart valve issues, and congestive heart failure are other types of heart disease.

Atherosclerosis is the process in which fatty substances, cholesterol, and other substances build up in the inner lining of arteries. This plaque forms slowly and over decades, often starting in childhood. Risk factors for atherosclerosis include family history of heart disease, high blood pressure, smoking, elevated cholesterol, diabetes, being overweight, physical inactivity.

When plaque ruptures it forms a blood clot which blocks blood flow and may break off and travel to another part of the body. If a clot restricts a blood vessel supplying the heart it causes a heart attack. If it impedes circulation to a vessel in the brain it causes a stroke, the topic of my next post.

Strokes are the fourth most common cause of death of women in the U.S. A stroke occurs when blood flow to the brain is stopped or blocked and brain cells die.

Two types of strokes exist. The most common type is an ischemic stroke, which occurs when blood flow to the brain is blocked, typically by atherosclerosis or a blood clot. The other kind of stroke is hemorrhagic, or bleeding in the brain. This occurs when a blood vessel in the brain bursts and blood bleeds into the brain. This can be caused by an aneurysm, which is a weakened spot in an artery that may rupture.

Both kinds of strokes cause brain cells to die. A small stroke could cause little brain damage where a large stroke could lead to significant impairments and possibly death. Depending on which part of the brain the stroke occurs one could experience difficulty with speech, memory, comprehension, vision, balance, and/or movement.

Some interesting facts about women and strokes:

• 1 in 5 women will have a stroke, compared to 1 in 6 men.

• It’s twice as common for women between the ages of 20 and 39 to suffer strokes as compared to men

• More women die from strokes than men

• More women than men have another stroke within 5 years of their first stroke

• Factors that increase a woman’s risk of stroke include pregnancy-related issues such as preeclampsia and gestational diabetes, use of hormonal birth control while smoking, and use of hormone therapy during or after menopause

• Certain risk factors are more common in women than men, such as migraine with aura, atrial fibrillation, and diabetes

Elevated blood pressure, smoking, and increased LDL (low-density lipoprotein) cholesterol are key risk factors for heart disease. About HALF of all people in the US have at least 1 of these risk factors.

The following also have been shown to increase the risk of heart disease in women:

• Diabetes

• Being overweight or obese

• Drinking alcohol excessively

• Physical inactivity

• Eating an unhealthy diet

• Menopause

• Pregnancy complications

• Mental stress and depression

• Family history of heart disease

• Inflammatory conditions such as lupus or rheumatoid arthritis

Signs of a heart attack include:

• Squeezing, pressure, pain, or fullness in the center of your chest

• Pain/discomfort in one or both arms, back, neck, upper abdomen, or jaw

• Shortness of breath

• Breaking out in a cold sweat, nausea, lightheadedness

• Fatigue

Chest pain is the most common symptom of a heart attack, but women are more likely than men to experience shortness of breath, vomiting, nausea, jaw pain, and back pain. Women are more likely than men to experience symptoms while resting or even when asleep. Many women ignore the signs of a heart attack because they can be subtle and confusing.

How can we reduce our risk of heart disease?

• Maintain a healthy weight

• If you smoke, stop. If you do not smoke at present, don’t start and avoid secondhand smoke

• Exercise at a moderate intensity most days. The Department of Health and Human Services recommends at least 150 minutes of moderate intensity aerobic exercise each week, 75 minutes of high intensity aerobic exercise per week, or a combination of the two.

• Eat a healthy diet

• Limit alcohol to no more than 1 drink/day (1 drink is 12oz of beer, 5oz of wine, or 1.5 oz spirits)

• Manage stress

• Manage other health conditions such as diabetes, hypertension, and elevated cholesterol

• Take medications as prescribed and follow the treatment plan developed by your health care provider

www.GoRedforWomen.org

has some excellent articles on heart disease in women.

March is Endometriosis awareness month, so I’ll share some information about this complex condition this month. Endometriosis is a condition in which tissue that usually resides in the uterus, the endometrium, grows outside the uterus. This tissue can involve the fallopian tubes, ovaries, and intestines. In some rare cases it has been found outside the abdominpelvic region. This endometrial tissue thickens, breaks down, and bleeds as hormones fluctuate throughout the menstrual cycle. Endometrium outside of the uterus has no way of exiting the body, so it becomes trapped. This trapped tissue thickens and can cause inflammation and the formation of scar tissue and adhesions, causing pelvic organs to become “stuck” together and irritating surrounding tissues. As you would imagine, this condition can cause excruciating pain which is often worse during menstruation. It can also cause fertility issues and heavy, irregular periods. Additionally, sex is often painful for women with endometriosis. 2-10% of women in the US between the ages of 25 and 40 are estimated to suffer from endometriosis. How is this condition diagnosed and what can be done to treat it? Stay tuned!

Endometriosis takes, on average, seven to nine years to be diagnosed. SEVEN TO NINE YEARS. This is due in part to normalization of painful periods by the medical community, especially family practitioners, who many women go to first, as well as women feeling embarrassed to discuss their menstrual cycle and symptoms with their provider. Patients suffering from “pelvic” symptoms (pain, painful periods, pain during intercourse) and higher BMI are likely go to longer before being diagnosed with endometriosis. Endometriosis can start as early as a girl’s first period and symptoms may persist past menopause, especially if a woman has extensive scar tissue and adhesions.

There isn’t one easy test to diagnose endometriosis, unfortunately. The only way a clinician can test for endometriosis is by performing a laproscopy and looking for endometrial tissue in the pelvis and abdomen. This is obviously very invasive and many patients aren’t able to find a practitioner who has enough knowledge about endometriosis to recommend laproscopy. The symptoms endometriosis causes can mimic other conditions, which adds another layer of confusion for both patients and health care providers. For example, a study by the World Endometriosis Research Foundation found that 50% of patients referred to a gastroenterologist for bowel issues actually had endometriosis, not bowel issues.

The physical symptoms of endometriosis – pain, diarrhea, constipation, bloating, urinary urgency/frequency, painful urination, pain during intercourse, painful/heavy periods – can clearly be agonizing. The impact of the physical symptoms of endometriosis has been found to be similar to the physical toll women undergoing cancer treatment endure. Overall time lost from work due to endometriosis symptoms has been estimated to be 8-10 hours/week.

There is no known cure for endometriosis. There are some medications that are marketed as treatment for endometriosis, but it is inadvisable to stay on them long-term due to side effects. Some researchers have found progestogenic birth control pills (birth control pills containing the synthetic form of the hormone progesterone) may be effective at reducing endometrial growths, although it is unclear if this also protects fertility. Hysterectomy is not a guaranteed treatment for endometriosis as endometrial tissue may be outside of the uterus. As of now, the gold standard treatment of endometriosis is laproscopy. Surgeons who are highly trained and experienced in treating women with endometriosis are able to explore the pelvic and abdominal cavities and remove scar tissue and endometriosis deposits. It is imperative that the surgeon performing this procedure has extensive knowledge and skill in performing this procedure, and unfortunately there are very few in the US who excel at it. Be sure to ask your surgeon how many of laproscopies she/he performs on patients with endometriosis monthly and her/his success rate.

Here are some excellent resources for anyone interested in learning more about endometriosis:

Nancy's Nook is an outstanding resource for information about endometriosis and for help finding an endometriosis expert:

https://nancysnookendo.com/

This is an excellent blog by one of the top endometriosis experts in the US:

https://topendodoc.com/

This book was written by a physician specializing in endometriosis and a pelvic floor physical therapist. It's full of evidence based information and is another great resource:

http://www.healpelvicpain.com/beating-endo

As the Endometriosis Foundation says, killer cramps are NOT normal! Let's continue to educate both women and providers about this painful disease and get women the help they need and deserve!

April is Irritable Bowel Syndrome awareness month, so let's learn more about this condition that impacts up to 45 million people in the US and 10-15% of the worldwide population (and, of course, how pelvic floor physical therapy can help! :))

Irritable Bowel Sydrome (IBS) is the most common functional gastrointestinal disorder and affects men, women, and children, although 2 out of 3 individuals suffering with IBS are women. In fact, it is estimated that 20-40% of all visits to gastroenterologists are for IBS. A recent survey by the International Foundation for Gastrointestinal Disorders found that patients suffered with IBS for an average of 6.6 years before being diagnosed.

Symptoms of IBS include abdominal pain associated with changes in bowel habits, such as periods of constipation and/or diarrhea. Individuals with IBS may experience periods of alternating symptoms, which can be confusing and frustrating. IBS symptoms range from being manageable to severely disabling and limiting one's quality of life.

The most common symptoms of IBS are abdominal pain, most often associated with bowel movement, and changes in bowel habits (diarrhea, constipation, or both). Other symptoms include bloating, feeling that you haven’t finished your bowel movement, and whiteish mucus in your stool. Women often experience an increase in IBS symptoms during their periods.

The cause of IBS is unknown. Current research indicates it may be due to how the brain and gut interact, and there may be a genetic component. Some postulate that depression, anxiety, stress, abuse, bacterial infections, small intestinal bacterial overgrowth, and food sensitivities may play a role in the development of IBS. Abnormalities in the nerves of the digestive tract may cause greater than normal discomfort when the abdomen stretches from gas or stool. Poorly coordinated signals from the brain to the intestines can cause an increased sensitivity to changes that normally occur during the digestive process, resulting in pain, constipation, or diarrhea.

Symptoms of IBS may be triggered by certain foods. Although everyone is an individual many note an increase in symptoms after consuming caffeine, chocolate, dairy, wheat, nuts, and high-fiber foods. Many IBS sufferers also note an increase in their symptoms during times of increased stress.

Up next: how can pelvic floor physical therapy help with IBS?

How can pelvic floor physical therapy help IBS? For starters, we can help patients establish a consistent bowel routine, educate patients about dietary triggers, and optimize toileting postures and voiding mechanics. We can work with your gastroenterologist, nutritionist, etc to ensure your daily habits are working for, not against, you.

Next, pelvic floor specialists are skilled at using a variety of techniques to calm the nervous system, such as breathing strategies, mindfulness, specific exercises/positions, to name a few. Exercise and yoga have been shown to help regulate bowel function in those with IBS, and your pelvic floor PT can help create a bespoke program tailored to you and the movements and exercise that you enjoy. Pelvic floor PTs are also highly skilled at addressing both myofascial and visceral issues, and can use these unique manual skills to ensure all the tissues in the abdomen, pelvis, thorax, hip girdle, and back are functioning optimally.

And, of course, pelvic floor PTs are adept at addressing any issues with the muscles, fascia, ligaments, and nerves of the pelvic floor. Individuals may present with weakness of the pelvic floor muscles, resulting in loss of stool and decreased rectal support. They may, instead, present with pelvic floor muscle hyperfacilitation, which translates to pain or difficulty relaxing the muscles around the rectum in order to have a bowel movement.

IBS is multifaceted and complex, and can wreak havoc on one’s quality of life. You don’t have to suffer alone, and I encourage you to find providers who are passionate about helping patients regain control and improve their quality of life!

April is also Cesarean Awareness Month! To start, here's a fantastic video clip of exactly what occurs during a C-section:

https://www.youtube.com/watch?v=ckQzMtptw4w

As you can see in the video I posted recently, a C-section is major abdominal surgery. I treat many women who have had a C-section, and believe every woman who gives birth should have a consult with a pelvic floor physical therapist. Many women who have had a C-section have not touched their scar, nor have they been instructed in how to massage their scar to reduce scar tissue. This is vital, as scarring from C-sections can contribute to pain during intercourse, urinary frequency, lower back pain, abdominal pain, and impaired function of the abdominal wall, to name a few. I’ve seen countless women whose children are in their twenties and thirties who have had chronic lower abdominal discomfort for years and were told by their OB/GYNs that this was normal. Pain is NEVER normal!

One patient that comes to mind was scheduled for exploratory laparoscopy for chronic abdominal pain for which she had seen countless gastroenterologists and gynecologists. She had been experiencing for 25 years, since her son was delivered via C-section. She was referred to me by her internist, who figured perhaps I could try some visceral mobilization techniques. This woman had not been able to wear jeans in 25 years and leaning her tummy against the kitchen counter was terribly painful. After 3 visits her pain was abolished and she canceled her surgery. What was the mysterious cause of this woman’s symptoms? Her C-section scar. Releasing adhesions at her scar and through her abdominal wall and teaching her techniques to do at home was all she needed.

Here is a video of the lovely Lynn Schulte demonstrating how to massage your C-sections scar. Whether your baby is 6 months old or 36 years old, it’s an invaluable tool!

https://www.youtube.com/watch?v=p-VfUJ6JcWo

May is Pelvic Pain Awareness Month. I’ve highlighted a few conditions over the past few months that can cause significant pelvic pain, including endometriosis and interstitial cystitis/bladder pain syndrome. Up next: vulvodynia.

Vulvodynia is chronic pain in the vulva, the external female genital anatomy including the mons pubis, labia majora and minora, clitoris, urethral meatus, vestibule (the tissue around the vaginal opening), and the Bartholin’s and Skene’s glands. Vulvodynia is basically pain in this region that lasts for more than 3 months and doesn’t have a clear identifiable cause, such as an infection, STD, or dermatological (skin) disorder. This pain can be constant or intermittent and may wax and wane depending on a woman’s hormonal cycle, stress levels, diet, activity level. The location of the pain may vary as well. Not surprisingly, sitting and sex can be quite painful, if not next to impossible.

There are two subtypes of vulvodynia, localized and generalized. Localized vulvodynia is pain in one vulvar location. If the pain is at the vestibule, the diagnosis may be vestibulodynia. The majority of women with vulvodynia have provoked vestibulodynia, which is when pain occurs during or after the vestibule is touched, such as with tampon insertion, sexual intercourse, wearing tight fitting pants, a gynecologic exam, and/or prolonged sitting. A less common form of localized vulvodynia is clitorodynia, or pain in the clitoris. As you may have guessed, this can be excruciatingly painful. Localized vulvodynia can be further classified as primary (vestibular pain since first attempt at vaginal penetration) or secondary (these women have experienced painfree intercourse and penetration before symptoms began).

Women with generalized vulvodynia experience more widespread pain in the vulvar region. Their symptoms are often relatively constant although there may be periods of symptom relief. Activities that apply pressure to the vulva may exacerbate their symptoms.

Researchers aren’t certain what exactly causes vulvodynia, but they speculate that vulvodynia may be caused by irritation or injury of the nerves that transmit pain from the vulvar region to the spinal cord. An increase in the number of/increased sensitivity of nerve fibers that sense pain in the vulva may also cause vulvodynia. Pelvic floor muscle overactivation or weakness may contribute, and there may be a genetic component.

Vulvodynia is diagnosed by ruling out active infection, sexually transmitted diseases, and dermatological conditions that could also cause vulvar pain and burning. A clinician will likely perform the cotton swab test, which involves gently touching around the vulva with a cotton swab and asking the patient to rate her pain when a specific area is touched. Many women see multiple providers before a diagnosis is made.

Because we aren’t sure what causes vulvodynia, treatments are directed at decreasing symptoms and developing an individualized program for each woman and her specific symptoms. A multidisciplinary approach is best, and a woman’s team may include a neurologist, gynecologist, pelvic floor physical therapist, pain management specialist, dermatologist, and/or urogynecologist. As this condition can take a toll on a woman’s relationships and emotional well-being, many women find seeing a mental health provider helpful. There is no one size fits all approach to treating vulvodynia (or any pelvic floor condition), it may take time to figure out what treatments are the most effective for you. Common treatments include pelvic floor PT, topical hormone creams or anesthetics, pain medication, nerve blocks, and avoiding irritants

Another condition women frequently see me for is dyspareunia, or pain during sex. This could be due to a variety of causes including but not limited to episiotomy, tearing during labor and delivery, trauma, menopause, pelvic organ prolapse, dermatologic issues, an orthopedic condition (such as a labral tear of the hip or thoracolumbar spine issue), and/or tightness/upregulation of the pelvic floor muscles. Also, any of the conditions I have previously posted about (interstitial cystitis, vulvodynia, pudendal neuralgia) can cause intercourse to be painful. It has been estimated that up to 60% of women experience pain during sex.

Pelvic floor physical therapists are uniquely trained to help women with this issue. Sadly, many women assume sex is supposed to be painful, or that it will never feel “normal” again after having a baby. This misconception is often reinforced by physicians. I’ve lost count of the number of women who have shared with me their provider told them to “just have a glass of wine,” or “use it or lose it, honey.” Nothing makes me angrier than hearing a woman’s legitimate concerns were dismissed and minimized. Dyspareunia can be devastating to a woman’s sense of self and can cause many issues in relationships.

According to the World Health Organization, the pursuit of a satisfying, safe, and pleasurable sex life is a human right. If you are experiencing pain during sex, I urge you to seek out a compassionate, skilled professional who will listen to your story and will help you regain your physical, mental, and emotional well-being.

June is Pelvic Organ Prolapse Awareness month, so I thought it only fitting that this should be the topic of my next few posts! Pelvic organ prolapse (POP) occurs when the muscles and connective tissues that support the rectum, uterus, cervix, and bladder weaken and become lax, allowing one or more of these organs to collapse into the vaginal walls. A cystocele, the most common type of prolapse, is when the bladder protrudes into the anterior wall of the vagina. A rectocele occurs when the rectum collapses into the back wall of the vagina. A uterine prolapse is when the uterus descends into the vagina.

There are a few risk factors for prolapse. Pregnancy increases a women’s risk of developing prolapse, and the risk increases with every delivery. The risk increases is greater vaginal deliveries, but even women who deliver via C-section are at risk. The second greatest risk factor for pelvic organ prolapse is obesity. Increased weight = increased downward load on the pelvic organs and pelvic floor muscles. Advancing age is another predisposing factor. Hysterectomy, scarring of the pelvic floor myofascial structures, and damaged/weakened pelvic floor muscles can lead to prolapse. Constipation, repetitive high-impact activity, and chronic coughing increase one’s risk of POP as they cause chronically increased intra-abdominal pressure. Smoking and connective tissue disorders can contribute to development of POP as they impact the ability of the fascial system to support the pelvic organs. Prolonged standing and poor posture are risk factors as well.

What does pelvic organ prolapse feel like? Some women say they feel a bulge in their vagina or that it feels like their organs are “falling out.” Others say it feels like they’re sitting on a tennis ball or an egg. Some will experience lower back and/or pelvic pressure and pain. POP can cause urinary incontinence, urinary urgency, constipation, incomplete emptying of the bladder. Sex may be painful. Some may see a bulge at the vagina when they bear down. It’s worth noting that many women with POP don’t experience any symptoms.

This condition can be embarrassing and painful, and it significantly impacts a woman’s quality of life. It affects her ability to be intimate, to exercise, to perform activities of daily living, to care for an infant, and her self-image.

Up next….what to do about it!

Treatment Options for Pelvic Organ Prolapse

My last post outlined different types of pelvic organ prolapse (POP) and why it occurs. What are a woman’s treatment options?

Pelvic floor physical therapy has been shown to be an effective treatment for POP. A 2016 meta-analysis and randomized clinical trial which included 2,340 women stated that women who received pelvic floor muscle training reported decreased symptoms associated with prolapse as well as objective improvements in the severity of the prolapse (see link below). Many women are advised to “kegel” for various pelvic floor conditions, but I would argue that it would behoove most women to consult a pelvic floor PT to ensure they are isolating the correct muscles as over half of women do active pelvic floor contractions incorrectly or, worse, in a way that worsens their symptoms.

Physical therapy treatment for POP should not be isolated to pelvic floor muscle training, though. It is also important to look at the entire women attached to that pelvis. How is she standing? Posture plays a huge role in how we can recruit the pelvic floor muscles and the management of intra-abdominal pressure. Is she constipated? If a woman is frequently straining she’s consistently putting downward force on her pelvic organs, potentially worsening her POP. How is she breathing? Many women hold their abdominal muscles tight and breathe shallowly, primarily moving their upper chests. As I outlined in an earlier post the diaphragm, our major muscle of respiration, and our pelvic floor muscles are teammates along with our abdominals. As the diaphragm contracts and moves down when we inhale, the pelvic floor gently attenuates this force and lengthens. It then rebounds back to its resting position upon exhalation. If someone is breathing shallowly and not getting full excursion of her diaphragm, her pelvic floor muscles won’t be able to perform as efficiently, thus providing her pelvic organs less support.

Another key thing a pelvic floor PT should examine is how someone manages intra-abdominal pressure. For example, many people hold their breath when going from sitting to standing or when lifting a toddler or bag of groceries. This strategy increases intra-abdominal pressure as a way to achieve stability rather than using deep stabilizing muscles for this purpose. This pressure has to be alleviated somehow and it will find the path of least resistance...which in many women’s case is down through her pelvic floor. This strategy puts a lot of downward pressure on the pelvic floor muscles and pelvic organs, and exacerbates POP symptoms. This is also a strategy I see many women employ when exercising, particularly when doing ab/core workouts and when weightlifting. A good pelvic floor PT should ask about your fitness routine and types of activities you perform regularly, and include bespoke exercises and treatments designed to maximize your ability to perform tasks that are important to you symptom-free.

Of course, pelvic floor PT cannot restore the elasticity of the fascia and connective tissue that support the pelvic organs, and it cannot fix every woman with POP symptoms. Some women find pessaries helpful. A pessary is a soft, removeable device that is inserted into the vagina, much like a tampon, and it provides support to the pelvic organs. There are many of different kinds of pessaries so you may need to try a few before you find the one that’s best for you. In the US women can get fit for a pessary by a urologist, urogynecologist, or OB/GYN.

The last resort for someone dealing with symptoms associated with pelvic organ prolapse is surgery. A surgeon uses either mesh or your own tissues to suspend the affected pelvic organ(s). This can be done abdominally, vaginally, or laparoscopically. It is estimated that 7-19% of women undergo some type of surgical repair for POP in their lifetime. Unfortunately, 1/3 of women who undergo POP surgery will experience a recurrence of their symptoms within five years. I’ve seen several women for pelvic floor rehab because their POP symptoms have returned after undergoing surgery, and it’s devastating. The type of repair and materials used obviously impact the surgical outcome, but if the contributing factors outlined in my previous post aren’t addressed, a woman is at risk of prolapsing again. It is essential to understand these risk factors prior to surgery and to know how to appropriately engage the pelvic floor muscles during functional tasks to give the newly suspended organs as much support as possible and prevent POP symptoms from recurring.

If anyone has questions or would like me to discuss anything mentioned in greater detail, please let me know. This is my passion and I want to help. Take care and have a great week!

https://pubmed.ncbi.nlm.nih.gov/26407564/

https://healthcare.utah.edu/publicaffairs/news/2013/05/05-14-2013_pelvic_organ_prolapse.php

Most people assume as a pelvic floor PT I spend every day only assessing and treating the abdominopelvic region. Nope! A skilled pelvic health provider should look outside the pelvis at other issues in the body that could be driving pelvic health concerns, from someone's neck down to her feet. Case in point: this study found a statistically significant relationship between foot flexibility and urinary incontinence in elite nulliparous female athletes. The decreased flexibility of the foot and calf likely decrease shock absorption, and this load is transmitted instead to the pelvic floor muscles. Just "kegeling" wouldn't have helped these ladies! If you are in need of pelvic floor physical therapy please try to find a provider who will spend at least 45 minutes with you, does a thorough examination, takes a comprehensive history, and possesses curiosity and compassion!

https://pubmed.ncbi.nlm.nih.gov/8649689/

This insightful study done by Fitzgerald et al in 2014 surveyed 311 female triathletes aged 35-44 years for several health issues. 37% had urinary incontinence, and, even more surprisingly, 28% experienced fecal incontinence. Just because you are an elite athlete or haven’t had a baby doesn’t mean you couldn’t develop pelvic floor issues. Leaking urine or feces is never normal, and it doesn’t have to keep you from participating in fitness activities you love. Consider consulting a pelvic floor physical therapist!

https://www.sciencedaily.com/releases/2016/08/160823165743.htm

Osteoporosis is a growing concern for women of all ages, especially those who are peri- and postmenopausal. The CDC estimates that almost 20% of women over the age of 50 have decreased bone mineral density in their lumbar spine and/or hip. Many women are instructed to increase their dietary calcium intake by drinking more milk and eating things like yogurt and cheese to prevent or combat decreased bone mineral density. Interestingly, the Harvard Nurse's Study, which was a 12 year study of more than 77,000 women, found no evidence to support this claim. Women who drank 2 or more glasses of milk daily had the same fracture risk as those who drank 1 or less glasses a week. Calcium intake is one small part of what should be a multifactoral approach to treating osteoporosis. What does lifestyle modification/intervention for osteoporosis does have robust evidence? EXERCISE. Weight bearing exercise has been shown to increase bone mineral density in individuals with osteopenia and osteoporosis. Some exercises may increase risk of fracture, however, so it's wise to work with a fitness professional or physical therapist who understands this condition and can create a personalized and safe fitness program for you!

https://pubmed.ncbi.nlm.nih.gov/9224182/

As a PT and Pilates instructor I frequently assess gluteal strength in my patients/clients as this muscle group not only is an important stabilizer of the pelvis and lumbar spine, but also is a “teammate” with the pelvic floor muscles. Curious what the best exercises are for gluteus maximus and medius? Forward step ups rank #1 for glute max, followed by single leg deadlifts, single leg squats, and wall sits. Side planks were found to activate gluteus medius the most, followed by single leg squats and single leg deadlifts.

https://pubmed.ncbi.nlm.nih.gov/22007858/

This systematic review of 33 studies examined the impact urinary incontinence and pelvic organ prolapse (POP) had on women's ability to participate in fitness activities. HALF of women across these studies stopped or modified their exercise regimen because of urinary incontinence, and women with pelvic organ prolapse also reported impaired ability to exercise. This inability to exercise has a devastating impact on women's bone health, mental and emotional well being, cardiovascular health, and quality of life. It increases risk of metabolic disease, Alzheimer's/dementia, and cancer, to name a few. Incontinence and pelvic organ prolapse are treatable conditions. Heath care providers, please screen your patients for these conditions as they can have far-reaching effects. Ladies, if you are experiencing symptoms of POP or urinary incontinence, please consider talking to your health care team or seeking treatment from a pelvic floor PT. We want to help you to live your best, healthiest life!

https://pubmed.ncbi.nlm.nih.gov/33971737/

I came across these studies regarding bra fit recently and found the results fascinating: up to EIGHTY PERCENT of women in the study wore the incorrect size bra! Women with larger breasts were more likely to be in the incorrect size bra. Poorly fitted bras impact the function of the bra, potentially leading to decreased support and increased breast bounce during activity. Both of these could cause women discomfort and embarrassment, and possibly impede their ability/desire to participate in fitness activities. Also, larger breasts have been shown to impact posture and increase pain. Breast size fluctuates throughout a woman's life and many advocate for being professionally fitted for a bra annually, or at least during puberty, early adulthood, pregnancy, postpartum, peri- and post menopause.

https://pubmed.ncbi.nlm.nih.gov/17205252/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2275741/

Constipation may not be the sexiest topic, but it’s a major driver of many pelvic floor issues and can make many issues worse. Let’s face it, when you aren’t going regularly it can be uncomfortable and upsetting. Regular bowel function is something we usually take for granted and don’t think about until things aren’t working as we’d like them to. Like I tell my son, everyone poops - so let’s talk about it!

“Normal” bowel function is defined as going anywhere from 3 times a day to 3 times a week. That’s quite a range, but you want whatever frequency is usual for you to occur consistently. I prefer my patients go at least once every day or so. Bowel movements are one of the ways our bodies eliminate waste and excess hormones, so they’re pretty important, especially for women. If stool is hanging out in the colon for a long period some of those water products may be reabsorbed back into the systemic circulation. Urinary frequency and urgency and incontinence are all more common in an individual who is constipated. Constipation can cause abdominal, pelvic, and back pain. It’s also a huge risk factor for pelvic organ prolapse (when the pelvic organs descend and collapse into the vagina and/or rectum). Hemorrhoids are another common consequence of constipation.

There are two main reasons for constipation. The first is delayed transit time. This is when the stool hangs out in the colon for a long time and too much water is reabsorbed, causing the stool to become hard and dry and difficult to pass. The second is pelvic floor dyssynergia, or when the pelvic floor muscles have a hard time relaxing. If the pelvic floor muscles cannot relax and allow sphincters to open, it’s super challenging to empty the rectum. It should take on average 24-48 hours for what you eat to come out the other end. Pelvic health providers use a tool called the Bristol Stool Scale to help patients describe their poop. Type 3 or 4 on this scale is ideal. If you see blood in your stool notify your health care provider immediately as this could be a sign of colorectal cancer.

Up next: ways to manage constipation!

Ways to improve bowel health

What you put in your mouth has a huge impact on bowel function. Many people find meat, dairy, fried or processed foods “bind” them up and interfere with healthy bowel function. Drinking plenty of water is key to keep things moving, and a diet rich in fruits, vegetables, nuts, and seeds will definitely improve bowel function. If you haven’t been eating much fiber, though, add it in slowly as a massive increase in dietary fiber can cause bloating and gas. Pre- and probiotics (fermented foods, dark green leafy veggies, yogurt) are helpful additions as well.

How you eat and your attitude about food influence your gut, too. When you eat, do you take time to think about what you’re putting in your mouth? Do you enjoy your food? Are you chewing your food well? All of these habits can impact your bowel.

Exercising for at least 20 minutes/day has been shown to improve bowel function. Another helpful trick is to have a warm beverage in the morning to get things moving. Caffeine is a bowel stimulant, but any warm beverage will work. The colon is a creature of habit, so trying to go at the same time daily can be helpful. Many people find 30 minutes after eating is often an optimal time. Don’t ignore the urge to go and be sure to allow yourself plenty of time so you aren’t rushing.

Did you know how you sit on the toilet can impact your ability to move your bowels? Ideally you should sit with your feet on a small stool so your knees are higher than your hips. The step stools little kids use in bathrooms work great, as do yoga blocks. Lean forward and place your forearms on your thighs while maintaining the gentle arch in your back. This straightens the anorectal angle and can make having a bowel movement easier. You should not need to strain excessively to force stool out and you should not hold your breath. You want to relax your pelvic floor muscles while generating gentle intra-abdominal pressure. Sometimes saying “grrr” or “shhh” can be helpful at achieving this balance in relaxation and pressure generation. If you experience difficulty relaxing your pelvic floor consider consulting a pelvic floor PT.

CCC Here is a link to a YouTube video of Michelle Lyons demonstrating a gentle abdominal massage technique that has been shown to promote motility of the colon. It’s also great for relaxing the abdominal muscles and facilitating the parasympathetic nervous system. I often recommend my patients do this upon waking in the morning, and many have found it helpful.

https://www.youtube.com/watch?v=7mWJ5noTO0U

Women have been historically underrepresented in biomedical research, and a recent study sheds light on this. Many researchers in the past shied away from including women in research populations because they didn’t want to be bothered with taking hormonal fluctuations associated with a woman’s menstrual cycle into account (don’t get me started on that one…). According to a study published last month by a team from Northwestern University and Smith College, the number of women included in biomedical research studies increased from 28% in 2009 to 49% but the number of studies that analyzed study results by gender did not improve or, as in the case of pharmacology studies, actually decreased.

This is distressing as efficacy of interventions may vary depending on the sex of the recipient. Metabolization of medications may vary between men and women, such as Ambien. Additionally, male senior investigators are overrepresented as principal investigators and may not have considered this issue. Sadly, fewer women have submitted to journals since the COVID pandemic shut many labs down in March 2020, which could further impact sex inclusion. Women are not small men, and need to be included in all levels of research.

https://elifesciences.org/articles/56344

https://www.sciencedaily.com/releases/2017/03/170327083455.htm

https://www.sleepapnea.org/learn/sleep-apnea/nighttime-urination-and-sleep-apnea/

I recently came across this study and found it fascinating and worth sharing. Many patients I treat experience nocturia, which is waking at night to urinate. As you can imagine, this can be quite annoying, can cause severe fatigue, and may occurring for a host of reasons such as medications, diet, pregnancy, etc. Well, here’s another: researchers have found a correlation between obstructive sleep apnea and nocturia. Over 84% of patients with sleep apnea in a study also complained of frequent nighttime urination. This correlation is so considerable that sleep researchers/clinicians feel nocturia is as significant as snoring when screening for sleep apnea! This relationship is important for anyone in pelvic health to keep in mind when treating individuals who experience nocturia, and individuals who experience nocturia should share this symptom with all members of their health care team, not just their urologist or gynecologist.

So worth a watch! Most pregnant women are educated about how to care for their newborn, but not at all about how to care for themselves postpartum. The information many view on the internet and social media is inaccurate and filtered. Women need and deserve comprehensive, individualized postpartum care, including pelvic floor physical therapy!

https://www.ted.com/talks/sara_reardon_rethinking_postpartum_care

Here is a helpful, easy to use tool to screen for pelvic floor dysfunction for both individuals as well as practitioners. Answering yes to 3 or more questions indicates pelvic floor dysfunction is likely. I hope this will help more people with PFD get diagnosed earlier and seek out pelvic floor physical therapy!

https://hermanwallace.com/blog/simple-screening-questionnaire-for-pelvic-floor-dysfunction

https://pubmed.ncbi.nlm.nih.gov/31813038/

I wanted to share this insightful study about weightlifting and pelvic organ prolapse (POP). Women who weightlifted heavy (>50kg) for fitness were LESS likely than those who lifted less than 15kg to experience POP. This is huge, because so many women are scared to try weightlifting for fear of developing or worsening POP. If any pelvic floor risk factors are taken into account and someone is supervised by a skilled, trained professional, from a pelvic health perspective there is no reason why women cannot safely participate in high-level fitness activities!😊

https://www.auanet.org/guidelines/guidelines/interstitial-cystitis-(ic/bps)-guideline

As September is Interstitial Cystitis Awareness Month I wanted to share the American Urological Association’s guidelines on the diagnosis and treatment of interstitial cystitis (IC). It’s worth noting the ONLY intervention to receive an A grade for strength of medical evidence is pelvic floor physical therapy. It is also suggested that pelvic floor PT should be a standard part of care for this patient population. I have posted in detail about IC, also known as Bladder Pain Syndrome, in the past so if anyone is interested in learning more about this condition feel free to check out those posts. If you or a loved one have been diagnosed with IC or think you may have it, please consider seeking out a skilled pelvic floor PT who has experience treating patients with this condition – it can make a huge difference in your pain, function, and quality of life!

"Females remain significantly underrrepresented within sport and exercise research. Therefore, at present most conclusions made from sport and exercise science research might only be applicable to one sex."

https://journals.humankinetics.com/configurable/content/journals%24002fwspaj%24002faop%24002farticle-10.1123-wspaj.2021-0028%24002farticle-10.1123-wspaj.2021-0028.xml?t:ac=journals%24002fwspaj%24002faop%24002farticle-10.1123-wspaj.2021-0028%24002farticle-10.1123-wspaj.2021-0028.xml

As many of you know, October is Breast Cancer Awareness Month. The Know Your Lemons Foundation is a great resource and has some fantastic graphics about breast anatomy and health and what some breast changes associated with breast cancer look like. Check it out and share - it might save someone you love's life.

https://knowyourlemons.org/

Pilates for the win! This large, well-done meta-analysis of 217 studies investigated which types of exercise are most effective at improving chronic lower back pain. Pilates came out on top along with McKenzie based exercises and functional restoration. That being said, ANY type of exercise is better than nothing, especially if it brings you joy. Movement is medicine!

https://www.sciencedirect.com/.../pii/S1836955321001028

This is a great TED talk by the fabulous Dr. Jen Gunter about menopause. So many women are confused about this time in our lives, and many are ashamed to ask their medical providers questions. I highly recommend Dr Gunter's new book, Menopause Manifesto, if you have more questions or would like more information about menopause. Women spend on average more than 1/3 of their lives in menopause, so we need to be better informed about how to prepare for this period (it starts earlier than you think - most women enter perimenopause in their 40's) and how to maximize our quality of life!

https://www.ted.com/.../jen_gunter_what_really_happens_to...

So many women love CrossFit and are eager to resume CrossFit workouts postpartum. Here is a nice piece that has some helpful tips and guidelines for returning to CrossFit after having a baby. Having a coach who has experience training postpartum women is ideal, and if you experience any incontinence, pain, or symptoms of pelvic organ prolapse PLEASE let your coach know and consider consulting a pelvic floor physical therapist!

https://thebarbellphysio.com/the-ultimate-guide-to.../

I recently had the privilege of attending Harvard School of Medicine's annual conference on Mind Body Medicine. I was blown away by the vast experience and diversity of the presenters and the robust research that supports interventions like diet, exercise, mindfulness to combat a host of conditions and improve quality of life. My favorite presentation was by Dr. Jud Brewer, who is a psychiatrist and neuroscientist specializing in anxiety. Here is a fantastic animation of how he approaches anxiety with his patients and tricks he uses to help them overcome it. I hope it's helpful! 🙂

https://www.youtube.com/watch?v=63O8kJBHK1s

I LOVE this study that was recently published in the Journal of Women’s Health Physical Therapy. Women experiencing urinary urgency and frequency were found to have less gluteal and hip rotator strength as compared to controls BUT similar pelvic floor strength. Surprised? It actually makes perfect sense and I am thrilled there is now evidence on this. So many of the women I treat with urinary urgency and/or frequency have overactive pelvic floor musculature. Their pelvic floor muscles aren’t weak, but the muscles in their hip girdles often are. If the glutes and hip rotators are weak the pelvic floor muscles will try to pick up their slack and work overtime, eventually resulting in shortened, hyperfacilitated pelvic floor muscles…which are a common cause of urinary urgency and frequency. As I say all the time, everything’s connected! The takeaway: we need to look at the entire woman, not just her pelvic floor, when she’s experiencing genitourinary symptoms (or any symptoms, for that matter!).

https://journals.lww.com/jwhpt/Abstract/2021/07000/Hip_and_Pelvic_Floor_Muscle_Strength_in_Women_With.5.aspx?mc_cid=9ba604e143&mc_eid=043e6672d1&fbclid=IwAR1MbyBikqNW1Sl4C208wCzH8s8I65U8uNe-nQwO97VhX0BwzYrZby3ri1M

Yet another reason to fit in a workout! This robust meta-analysis showed that high intensity interval training workouts can promote moderate improvements in mental well-being, depression severity, and perceived stress. Movement is medicine!

https://bjsm.bmj.com/.../2021/09/15/bjsports-2021-103984

Cesarean sections are the most commonly performed inpatient procedure in the US and are considered major abdominal surgery, yet women post C-section are rarely routinely referred to a pelvic health physical therapist. This valuable study shows how women s/p C-section who received 6 weeks of physical therapy had less back and pelvic girdle pain and had improved quality of life scores for up to 1 year post-op as compared to those who had "usual" postpartum care. A woman's body undergoes beautiful and drastic changes throughout her pregnancy, and to have to deal with the sequalae of a c-section afterwards (along with the responsibility of caring for a newborn!) can be overwhelming both physically and emotionally. Please consider seeking care from an experienced pelvic health PT if you had a c-section at any point. We'll help restore your physical, emotional and mental well-being ❤

https://journals.lww.com/jwhpt/Abstract/2021/01000/Physical_Therapy_in_Addition_to_Standard_of_Care.3.aspx?fbclid=IwAR3AV4ET33_8mgXDAEWRI941QMiMs0wgS5IN92zkkN6b9ngceZXeeaBrCsU

This brief video by the genius Dr Lorimer Moseley is a must see for anyone suffering with chronic pain. He outlines current pain research and strategies to retrain pain and the nervous system. His website, www.tamethebest.org, is another fantastic resource!

https://www.tamethebeast.org/#tame-the-beast

I was excited to see this article and thought it was worth a share as it explains the concept of core stability in an approachable way. So many people assume their "core" is simply their abdominal muscles. Our core is actually comprised of muscles throughout our hips and buttocks, back, abdominals, and pelvic floor, as well as our diaphragm. It's important for these muscles to be strong AND supple, and to be able to work dynamically. I also love that the author mentions the importance of NOT "sucking in" all the time as this contributes to urinary incontinence and pelvic organ prolapse.

https://www.marthastewart.com/8243304/how-strengthen-core

"These studies suggest that the female body may be more resilient, dynamic, and expansive than science has historically considered it. To rethink the ovary is to open the door to questioning a whole host of things that everybody knows are "true" about the female body. It is to reimagine how the female body works - and rethink what all bodies are capable of."

https://www.nytimes.com/2022/03/29/opinion/ovaries-stem-cells-fertility.html?fbclid=IwAR257AWDgjfufQlTfJUvs_egjIGGMak5pUaqgy_PS2PDz3yboO4aIUAGxWI

April is National Limb Loss & Limb Difference Awareness Month. In celebration and recognition, Catalyze Physical Therapy & Pilates will be featuring a guest blog.

Pelvic stabilization and core strengthening are key components to energy efficient, fluid prosthetic gait. An individual with a prosthesis can use 100-200% more energy to walk. Less muscle mass, shorter lever arms and changes to the vascular system are a few of the intrinsic factors leading to this high energy cost. Compensations to combat this start off small and lead to bigger problems. Overuse, muscle imbalance and postural asymmetries can lead to osteoarthritis, osteopenia and chronic low back pain. Starting off with the right posture and a strong foundation can help counteract these issues.

Muscles of the hip girdle play a large role in typical gait and the need for them is highlighted with prosthetic gait. When we walk, we transition from phases of stance when we stabilize on one leg, and swing when we advance our opposite leg. A prosthetic user must use available muscles to stabilize their residual limb in the socket to maintain balance and control when standing on the prosthesis. This availability to recruit and stabilize depends on the level of amputation; the higher the level of amputation, the shorter the residual limb and less muscles available. Regardless of the level, hip strength and pelvic rotation are vital. Using our large hip extensor muscles, we can help stand upright, support our body and counteract our body’s natural falling forward with walking. Without the sensory input from an anatomic foot, a prosthetic user must rely on muscles and nerves higher up in the body for feedback and stabilization. The hip extensors keep the residual limb positioned well in the socket and help to direct the prosthetic knee and foot how to operate. Pelvic stability and rotation are key to advancing the prosthesis. This allows the user to take a more natural step forward without hiking the hip or swinging it around. For those with an above knee amputation, this motion helps to unlock the prosthetic knee allowing it to bend to take a step. Strengthening these muscles, along with the hip abductors and abdominals, and stretching the hip flexors by laying prone everyday can be instrumental to helping reduce the risk of low back pain and lead to higher activity levels.

For every individual, effectively functioning core and pelvic floor musculature are the foundation for a healthy lifestyle. Sound stability lends to dynamic mobility. Every motion we perform stems from this focal point of control. From lifting our own body weight to stand, advancing a prosthesis to ascend stairs to raising a child up in the air in a celebratory hug, we rely on these muscles to be properly engaged to avoid injury and achieve our goals.

Adrienne Oliveira, PT, DPT

Adjunct Professor of Physical Therapy at Quinnipiac University & Sacred Heart University

PT Coordinator of Prosthetics & Orthotics Clinic, Gaylord Hospital

Over TWO MILLION person-years were examined in this high quality study regarding physical activity and depression, and the researchers concluded "Based on an estimate of exposure prevalences among included cohorts, if less active adults had achieved the current physical activity recommendations, 11.5% of depression cases could have been prevented." Reaching even 50% of the recommended activity level was sufficient for risk reduction, and hitting the guidelines provided even more benefit. Movement is medicine!

https://jamanetwork.com/.../jamapsych.../fullarticle/2790780

“No one ever told me this could happen.” This is the #1 statement I hear from patients who are experiencing symptoms of pelvic floor trauma postpartum, which can include urinary and/or fecal incontinence, pain during sex, abdominal pain, and a sensation of pressure or bulging in the vagina or rectum. If expectations of the early postpartum experience do not correlate with one’s expectations this can be distressing, and may also negatively impact one’s mental and emotional wellbeing. Many women also share similar sentiments in regards to the demands of parenting and shifts in identity. As demonstrated in the following study, women reported a lack of education regarding pelvic floor issues and potential birth-related injuries, and significant associations were seen between pelvic floor symptoms and psychological distress. Also, women who reported a high discrepancy between expectations of the postpartum experience and what actually transpired were more distressed by pelvic floor symptoms. Sadly, many providers do not discuss these issues with women during pregnancy or at postpartum follow up visits, and many women feel abandoned and unsupported during this critical time. “These findings counter the notion that information begets fear; we do not anticipate that comprehensive pelvic floor education would generally result in increased distress during or following pregnancy. Importantly, providing pregnant people with accurate information that can be used to make decisions is not in conflict with empowered birth. On the contrary, having sufficient knowledge to maintain agency and make informed decisions is generally considered a critical aspect of positive birth experiences.” Information is power, and both health care providers and women themselves need to promote and continue this conversation!

https://journals.lww.com/jwhpt/Fulltext/2022/04000/The_Importance_of_Information__Prenatal_Education.2.aspx?fbclid=IwAR1UVSupwGJtve1OmQOYR4Qrc-YB2bX7Ce4-e1PwCVJup_zC1mOg69YMn8o

I highly recommend "Why Did No One Tell Me? How to Protect, Heal, and Nurture Your Body Through Motherhood" by internationally recognized pelvic health physiotherapist Emma Brockwell to all pregnant and postpartum women. It's an invaluable resource with tips for healing after vaginal deliveries and c-sections, how to safely resume exercise postpartum, and explanations of common (and treatable!) issues many women encounter post-birth, such as incontinence, pelvic organ prolapse, and diastasis rectus abdominis.

https://www.penguin.com.au/books/why-did-no-one-tell-me-9781473581098

I am a firm believer that every woman deserves and needs an assessment by a pelvic health physical therapist postpartum. This should be standard care, not something someone has to seek out on her own if she experiences issues or has questions after having a baby!

*** https://www.girlsgonestrong.com/blog/pregnancy/every-new-mother-see-physical-health-physiotherapist/

Menopause does not signal “decay” or “decline,” nor is it a “hormone deficiency disease.” It is a normal life event experienced by half the population. This op-ed recently published in the esteemed British Medical Journal explains that women’s experiences vary around the globe and, unfortunately, medicalization of menopause often prepares women to expect the worst. It’s worth a read, and here are the take away messages:

1. Menopause is a natural event for half of the population, but there is no universal experience.

2. Experience of menopause is shaped by social, cultural, and biological factors.

3. The medicalization of menopause reinforces negative views about reproductive aging.

4. Although some women with troublesome menopausal symptoms may benefit from menopausal hormonal therapy, other effective treatments are widely available and a narrow focus on symptoms fuels negative expectations.

5. Challenging gender ageism, reducing stigma, and providing balanced information about menopause may better equip women to navigate this stage.

We need more conversations about menopause. People deserve to understand what’s happening with their bodies and how to best prepare for menopause!

https://www.bmj.com/content/377/bmj-2021-069369

Postpartum depression is estimated to affect 17% of women worldwide and 1 in 7 in the US. It is a serious condition which, if untreated, can wreak havoc on a woman's well being as well as on her interpersonal relationships and the emotional and cognitive development of her child. This isn't a "phase" or something that will simply pass, nor is it something to feel ashamed of. If you or someone you care about is experiencing PPD please seek help from a mental health provider and talk openly to someone you trust about your feelings. Postpartum depression isn't your fault. It's a real, treatable psychological disorder.

https://www.apa.org/.../res.../reports/postpartum-depression

This 2021 study out of the European Journal of Sport Science looked at athletic performance of elite female marathoners before and after having a baby. 37 out of the best 150 female marathoners listed in the IAAF's All-Time Marathon Top List had 1 or more children mid-career. Twenty-six of these runners (that's 70%!) had their personal best times postpartum. Rock on, mamas! 🏃‍♀️❤️

https://www.tandfonline.com/.../17461391.2022.2089054...

50% of women over the age of 65 will develop urinary incontinence.

3% of providers regularly screen for urinary symptoms.

WE CAN DO BETTER.

https://pubmed.ncbi.nlm.nih.gov/34416944/

As many of you already know, October is Breast Cancer Awareness Month. Coppafeel! is a wonderful nonprofit organization out of the UK dedicated to promoting breast health awareness to women of all ages. The website, www.coppafeel.org, includes a link that walks through how to do a self exam and answers many commonly asked questions. If you know what your "normal" is, you're more likely to notice a change and consult your health care provider. You can even sign up for free monthly reminders via text to do your self-exams!

According to the American College of Obstetricians and Gynecologists, menstruation should be considered the fifth vital sign (other vital signs you're probably already aware of include heart rate, blood pressure, and respiratory rate). Tracking periods to assess cycle length and symptoms can provide helpful information about possible health issues such as endometriosis, PCOS, or thyroid dysfunction. It can also alert women about when they're possibly entering perimenopause. Whether you're a pen and paper gal, you prefer to track data on your phone, or you use one of the many apps that exist for this purpose. keeping tabs on your cycle is a wise idea for all women, and our cycle is something we should discuss more often with health care providers.

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/12/menstruation-in-girls-and-adolescents-using-the-menstrual-cycle-as-a-vital-sign?fbclid=IwAR3mBrpXjvLH6i4445-1NjXRSqzDGpY4giFZ59zObuuVczbP-K_NeJC7rJs